In February's Opinion ("Too Err Is Human: To Apologize Divine?"), Dr. Mills extols the virtues of an article on "Apology in Medical Practice: An Emerging Clinical Skill."1 I agree that this is a superb philosophical dissection of the structure and use of an apology. Dr. Mills has concluded from this article that it would be a good idea for physicians to begin to use an apology in the appropriate circumstance.

I was so favorably impressed with the original article that I called the author, Aaron Lazare, MD, and he was kind enough to have a lengthy conversation with me. His discussion has led me to realize there are two critically important caveats before any physician attempts an apology after an adverse event. The first is that there are only four states that have passed legislation preventing the substance of an apology from being used against the physician in court: Arizona, Colorado, Connecticut and Georgia.

The second is that no physician should make any attempt at an apology without first consulting a risk manager from a medical malpractice insurer because acting without the imprimatur of the insurance company may jeopardize the physician's coverage as well as the defense of litigation. To be as safe as possible, before entering this brave new world, the physician should also consult with an experienced attorney who is fully conversant with personal injury law.

Marvin F. Kraushar, MD Westfield, N.J.

___________________________ 1 Lazare, A. JAMA 2006;296:1401-1404.

EyeNet asked Ophthalmic Mutual Insurance Company (OMIC) to review Dr. Kraushar's letter. The following is their response.

More than 30 states have laws ("apology statutes") that make statements of apology inadmissible in court.

Currently, having the legal support from these statutes, medical malpractice insurance carriers, including OMIC, publish detailed protocols to actually facilitate an apology. Ideally, ophthalmologists should first confer with their insurance carrier's risk manager prior to having such a discussion.

However, if this is not feasible, it would be extraordinary for a carrier to cancel coverage because an apology was somehow given ineffectively.

Last spring, the Academy surveyed 239 ophthalmologists who were in their first five years of practice regarding how well their residency training had prepared them for practice. The full report of this survey was published in February's Ophthalmology.

The survey results showed that the majority of recent graduates believe that they received adequate clinical training in residency but that they did not receive adequate education in various nonclinical areas such as practice management, finance, coding and political advocacy. Additionally, the majority of the respondents believed that it was the responsibility of their residency programs to teach them such nonclinical skills.

As one of the coauthors of the study, I believe the results are not surprising given that ophthalmology residencies, like all medical residencies, are traditionally clinically focused. However, the study's majority opinion—that nonclinical topics should be taught in residency—is important new information. This survey has revealed a need within our residency training system.

The Academy has begun dialogues with the training programs and others in the ophthalmology community to start addressing the challenge of providing additional education in nonclinical areas.

The Academy has also already put into place many resources for residents on nonclinical topics: a BCSC companion book (The Profession of Ophthalmology) and free membership in AAOE for third-year residents are a couple of examples.